Last fall’s transition to the highly specific ICD-10 medical coding system went smoother than many expected. But the end of a grace period that had allowed for extensive use of more generalized, unspecified medical codes could create problems for anesthesia practices.

On Oct. 1, 2016, the Centers for Medicare & Medicaid Services (CMS) closed a one-year window that had prohibited Medicare review contractors from denying ICD-10 claims based solely on the specificity of diagnosis codes. The CMS moratorium allowed healthcare organizations to use unspecified medical codes in place of detailed diagnosis information and was designed to help smooth the transition to ICD-10. Privatized Medicare plans and commercial insurers likewise have provided groups with medical coding flexibility and consequently are also expected to restrict the permissible use of unspecified codes.

The end of the grace period, however, does not mean unspecified codes will disappear. In ICD-9, CMS historically allowed for the limited use of unspecified medical codes. The agency has stated that in the ICD-10 environment, unspecified codes may continue to represent the optimal choice to accurately reflect the healthcare encounter in some cases if sufficient clinical information is unknown or unavailable.1

But because it is still too early to determine what CMS will consider appropriate use, practices should take steps to further strengthen physician documentation to reduce the application of unspecified codes. By doing so, it will help mitigate the risk of potentially costly claim denials and cash flow interruptions.

Anesthesiology challenges

Anesthesiologists face unique difficulties when it comes to ensuring greater documentation and medical code accuracy. Because they’re involved in a wider range of procedures, anesthesiologists face a greater number of diagnosis codes than typically is the case for other specialties, including pathologists and radiologists.

In addition, CMS expects anesthesiologists to have access to detailed diagnosis information because the physicians are providing services near the end of the episode of care. For example, a pneumonia diagnosis that isn’t identified as either viral or bacterial may be appropriate for an emergency department doctor; but, a similar lack of disease etiology information will now likely result in a denial for an anesthesiologist.

Finally, accessing the most current diagnosis information can sometimes be problematic if the surgeon is uncertain about the diagnosis or if he or she is unable to share the information in a timely fashion. Less-than-optimal cross-specialty communications can therefore contribute to the absence of required information.

Studiomaca Business Performance Services has tracked unspecified medical code usage across its anesthesia client base since ICD-10 went into effect on Oct. 1, 2015. In the month of August 2016, the data showed unspecified codes accounted for 39% of all diagnosis codes in anesthesia for all payers. For Medicare, the unspecified code rate was 34%. Of all the unspecified codes, approximately one-third involved just 12 diagnostic areas. By attacking high-frequency unspecified codes areas, unspecified use could be reduced significantly.

Cataract medical coding complexities

Cataract surgery represents one high-volume, Medicare-reimbursed procedure where etiological details frequently are lacking and as a result, high rates of unspecified codes ensue. The issue lies in the fact that ophthalmologists don’t always dictate thorough operative notes due to the volume of surgeries they conduct.

Here are the areas that anesthesiologists now need to differentiate and document in order for cataract procedures services to be appropriately coded in ICD-10. Generally speaking, physicians should document the diagnosis description to the most granular subcategory possible. In virtually all instances, this includes specific information about location and laterally:

  • Age Related/Senile - most common but must be specified on every case
    • Subcategory Choices:
      • Cortical
      • Anterior subcapsular polar
      • Posterior subcapsular polar
      • Other
      • Nuclear
      • Morgagnian type
      • Combined
    • Other Categories:
      • Infantile and Juvenile
        • Subcategories same as age related above
      • Traumatic cataract
        • Localized
        • Partially resolved
        • Total
      • Complicated cataract
        • Neovascularization
        • Secondary to ocular disorders
        • Glaucomatous flecs
        • Drug induced cataract
        • Secondary cataract
          • Soemmering’s Ring
          • Other
  • Other specified cataract
A multi-faceted approach for strengthening physician documentation

The following represent several steps that organizations can take to help improve the collection of necessary diagnosis details across all procedures in order to strengthen specificity and thus reduce claims denial risk:

  1. Foster an anesthesia-provider/surgeon relationship that is conducive to improved operating room communication and the timely exchange of information. The optimal solution typically is to obtain this information during a time-out at the end of surgery. Another approach may be for the anesthesia group to take a more active role in operating room management or peri-operative care. For example, establishing a pre-operative screening clinic for high-risk patients could help improve patient safety while strengthening communication channels with surgeons.
  2. Mirror as close as possible, the surgeon’s submitted diagnosis and procedure codes. Otherwise, the medical claim runs the risk of denial. Accessing surgeon’s dictated post-operative notes should be used as a last defense to help ensure appropriate coding.
  3. Create mechanisms that enable coders to quickly reach out to clinicians to obtain missing or incomplete diagnosis information. Develop a system that regularly provides anesthesiologists with feedback and education about reoccurring or problematic areas of documentation specificity.

Studiomaca understands the impact that elimination of the ICD-10 grace period may have for anesthesiologists and how critical it is for groups to provide documentation that can support the highest level of coding specificity. Our coding, compliance and operations teams review denials on a weekly basis to uncover any negative trends. Results are then assessed to determine the root causes of denials so corrective action plans can be established. Through these and other efforts, Studiomaca works to provide the highest level of revenue cycle services and financial reporting for anesthesiology to help groups negotiate today’s difficult and fast-changing healthcare terrain.

1 “ ,” MLN Matters #SE1518, Department of Health and Human Services, Centers for Medicare & Medicaid Services

Sheree Benner

About the author

Sheree Benner, MBA, CPC, CPPM

Client Manager, Anesthesia
Studiomaca Revenue Management Solutions